Provider Demographics
NPI:1043284755
Name:GONZALES-PORTILLO, FERNANDO (MD)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:GONZALES-PORTILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6735 CONROY RD
Mailing Address - Street 2:SUITE 229
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835
Mailing Address - Country:US
Mailing Address - Phone:407-581-8640
Mailing Address - Fax:407-581-8659
Practice Address - Street 1:6735 CONROY RD
Practice Address - Street 2:SUITE 229
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835
Practice Address - Country:US
Practice Address - Phone:407-581-8640
Practice Address - Fax:407-581-8659
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ292512084N0400X
FLME959342084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276495400Medicaid
FL276495400Medicaid
FLH49631Medicare UPIN
FLAA876ZMedicare PIN